Community hospital service review Public workshop 3: How services are provided and best practice in community care The third round of public engagement workshops for the Community Hospital Services review began on Monday 13th June and looked at how services (particularly inpatient services) are currently provided, and how we develop a model of what we would consider best practice for community hospital care. The table below lists the workshop dates, location and number of people who attended: Date Location Attendance Monday 8 June 2015 Tuesday 9 June 2015 King George s Hall High Street, Esher, Surrey United Reform Church, Dorking 11 3 Wednesday 10 June 2015 Leatherhead Hospital 29 Thursday 11 June 2015 St Joseph s Catholic Church (Chatterton Room), Epsom 6 As with previous workshops, this round saw reasonable attendance. Lower attendance was noted during the evening sessions, however, these were still considered critical so that those who work during the day have a chance to attend. The workshop at Leatherhead hospital was best attended with 29 attendees. As with workshops 1 and 2, each of the four sessions for workshop 3 followed the same format; enabling individuals to attend the session best suited to them over the week period. Attendees were asked to sit in an informal group circle to facilitate open discussion. Session-specific queries are noted at the bottom of this document.
Some issues with the room layout for the Leatherhead workshop were noted, as only half the number had booked onto the session and therefore the room was originally laid out for a smaller group. Feedback from this event will be taken on board in the planning for workshop 4 and, if necessary, two smaller working groups will be formed. Attendees are encouraged to re-book onto the next session so that numbers can be confirmed in advance. Workshop 3 focused on: How services (particularly inpatient services) are currently provided across the community hospitals. For Leatherhead hospital, this would include looking at previous data of when Leach ward was operating out of the Leatherhead site How services are performing against quality metrics Operational issues to consider in moving forward What best practice in community inpatient care looks like nationally and within our four community hospital sites and how this compares with patient expectations and agreed standards How agreed best practice can be implemented across the whole of Surrey Downs and any alternative models of care Next steps for the review Each workshop was opened with all participants being asked to introduce themselves. The meeting chair then updated the group on the progress of the review to date. This explanation focused on the initial findings of the activity review, which included details of the current sites with inpatient provision: New Epsom and Ewell Community Hospital (NEECH) a 20-bedded ward which receives patients from Epsom and St Helier hospitals, as well as from community clinicians. The ward has 16 general rehabilitation beds and four dedicated to neurological rehabilitation. Five of the general rehabilitation beds were previously located at Leach ward in Leatherhead Community Hospital. NEECH provides outpatient services including physiotherapy. It is also a base for the community nursing services. The ward is bright and welcoming, having been refurbished around 12 months ago. The average length of stay for patients is approximately 22 days and following site visits, the quality of clinical care was considered to be high. Dorking Community Hospital a 28-bedded ward which receives patients from Epsom and St Helier hospitals, Surrey and Sussex Hospital, and from community clinicians. The 28 beds are all dedicated to general rehabilitation. Ten of the general rehabilitation beds were previously located at Leach ward in Leatherhead Community Hospital. The hospital also provides a comprehensive range of outpatient services including physiotherapy and x-ray. It is also a base for the South East Coast Ambulance Service NHS Trust (SECAmb). The ward area is larger than NEECH. It is a bright space with a large communal area for patients. The quality of
clinical care provided is also considered to be high. The average length of stay for patients is approximately 14 days Molesey Community Hospital a 12-bedded ward which receives patients predominantly from Kingston Hospital, with a small number from community clinicians. The 12 beds are all dedicated to general rehabilitation. The hospital also provides a range of outpatient services including physiotherapy. The ward area is spread out over three corridors. The female beds are at one side of the building, male beds in at the other side, with side rooms located in the corridor connecting the two sides of the ward. It has a bright space with a large communal area for patients. Following site visits the quality of clinical care provided is also considered to be very good. The average length of stay for patients is approximately 25 days Leatherhead Community Hospital currently provides a large range of outpatient diagnostic services, from a number of providers, including: Epsom and St Helier University Hospitals NHS Trust: X-ray department, colposcopy service, and outpatient clinics for orthopaedics, dermatology, cardiology and ophthalmology CSH Surrey: Community assessment unit (limited), child development clinic, continence nursing service, outpatient physiotherapy service and gym Virgin Care: Sexual health service Leatherhead hospital is also used by CSH Surrey for a number of administrative services, including HR. Until late 2014, the hospital provided 15 inpatient beds (with an 18-bedded capacity) as part of its Leach Wards. These beds have currently been moved to Dorking and NEECH (as stated above). Leatherhead is a well-visited location, with strong local community support. The quality of clinical care (both currently and at Leach ward) has been shown to be very high, as with the other community hospitals. Data for Leach ward was included with the other three sites in comparative discussions throughout this workshop (see graphs below). This was to ensure that Leatherhead hospital is given equal consideration when matching population needs to future options for inpatient services, despite beds currently being moved from Leach ward into Dorking and NEECH. All three hospitals with inpatient beds have been receiving patients with limited potential for rehabilitation. Some work needs to be done to align the assessment and referral process between the acute and community hospitals to ensure best use is made of the rehabilitation services. Current services provided out of other sites without (currently or in the recent past) inpatient beds were also discussed:
Cobham Hospital A large relatively new site, originally build to house both outpatient services and inpatient beds. Currently has a diagnostic treatment centre, physiotherapy services, sexual health services and a number of day clinics. There is also a day case treatment centre at the front of the site. Emberbrook Health Centre (Thames Ditton) A range of outpatient services, including district nursing, podiatry and physiotherapy. The centre is collocated with a private nursing home. In the past the local NHS has held a contract with the nursing home for NHS beds, however this arrangement ended some years ago. Changing population The group was presented with information on the expected population changes over the next ten years. The table below illustrates the anticipated increases in the population aged 65 years and over: Table 1. Population changes in over 65yr old categories. The data was then discussed in terms of risk stratification, which predicts how population changes will alter health needs. The group discussed the slow increase in the population over the next 10 to 15 year period and the health requirements that these age groups will have. To better show the changes the group was presented with the graphs below: Graphs 1a,1b, 1c, 1d and 1e Changes in population volumes over time
These graphs illustrated that segments of the population actually decreased in number before increasing again. The group discussed how this would impact on the demand for community beds. The discussion then focused on how the number of patients was not the only factor dictating bed capacity. The review also had to look at the prevalence or incidence of chronic disease. Initial review of the risk stratification data indicated that the incidence of disease would rise greater than the 2% increase in population. It is estimated that the incidence of disease could be around 4%. Applying this increase to the current numbers of patients using the community hospitals gives a steady increase in demand for beds. The table below illustrated this increase: Table 2. Beds capacity based on 4% increase Year Patients Beds 2015 880 60 2016 915 61 2017 952 63 2018 990 66 2019 1029 69 2020 1071 71 2021 1113 74 2022 1158 77 2023 1204 80 2024 1253 84 The group could identify that, without efficiencies or alternative options for rehabilitation, Surrey Downs would need 84 beds by 2024. However, this does not take into account the CCG s other plans including the introduction of community medical teams and multidisciplinary specialist teams and other initiatives aimed at reducing admissions. Looking at quality measures Each workshop session looked at the data on the average length of stay and the occupancy levels of the four hospital sites, including data for Leach ward in Leatherhead. Comparisons were made between the sites and areas of best practice were identified. The issue of how these markers compared to other quality measures (such as patient satisfaction, clinical outcomes, readmissions, CQC inspection scores and infection control rates) was discussed and it was noted that these were all of a similar high standard and therefore not comparable.
Following the site visits, all four community hospital sites show high standards of care, staff dedication and high patient satisfaction. However, the average length of stay and occupancy rates vary depending on the size of the unit and individual community hospital working practices. Length of stay ranges from 12 days in Dorking to 25 days in Molesey. When comparing data neuro-rehabilitation bed data was not included for NEECH. This is because patients using these beds are receiving specialised treatment and often require much longer lengths of stay. The graphs presented to the group are shown below. Graphs 2a, 2b, 2c and 2d Average Length of Stay The data shows Dorking performing well with an average length of stay now at around 12 days. NEECH patients are staying an average of 22 days whilst Molesey patients stay an average of 25 days. Leatherhead patients were having stays of around 21 days prior to the beds being relocated. The groups discussed the Dorking length of stay which has been dropping most significantly since the end of 2014,
following the transfer of the additional beds. It was explained that this drop has coincided with the appointment of a dedicated Discharge Planning Nurse at the site. Using the Average Length of Stay data the activity of 2014 and likely activity of 2015 is shown below: Table 3: 2014 Average length of stay Site Beds % Occupancy Annual bed Days Dorking 22 85% 6826 20 341 Molesey 12 85% 3723 25 149 NEECH 11 85% 3413 20 171 Leatherhead 15 80% 4380 20 219 Total 60 880 Patient volumes This table represented the activity over the last year. The group discussed the different lengths of stay at each site, even though the hospitals are run by the same provider. Table 4: 2015 Site Beds % Occupancy Annual bed Days Average length of stay Patient volumes Dorking 28 90% 9198 15 613 Molesey 12 85% 3723 25 149 NEECH 20 85% 6205 21 295 Leatherhead 0 14 0 Total 60 1058 Table 4 shows that improvements in length of stay can increase the volume of patients able to be seen in the 12 month period. Dorking Hospital is currently achieving an average length of stay of less than 14 days.
Table 5 below demonstrates the capacity if this average length of stay were applied across all sites. Table 5: Potential Site Beds % Occupancy Annual bed Days Average length of stay Patient volumes Dorking 28 90% 9198 14 657 Molesey 12 85% 3723 14 266 NEECH 20 85% 6205 14 443 Leatherhead 0 14 0 Total 60 1366 Having a target of 14 days for the average length of stay will increase the bed capacity by 30%. The volume of patients able to be seen within current bed capacity is equivalent to the 4% increase in demand per annum for the next 10 years. Table 2 above has patient volumes at a maximum of 1,253 in 2024. The group discussed why the hospitals might be so different including the size and layout of the sites and the number of beds they have. As well as variances in the length of stay between the hospitals the group looked at the amount of time the beds were full; the occupancy levels. There is also a marked difference in the occupancy levels at each unit. CSH Surrey provided the data on the occupancy levels for Dorking, Molesey and NEECH for the first 5 months of 2015. CSH also provided data for Leatherhead; this relates to the 6 months prior to the beds being transferred. The occupancy data for the four sites has been charted below. Graphs 3a,3b, 3c and 3d - Occupancy Data for Community Hospitals
From the graphs the group could again see that Dorking achieves maximum occupancy almost all of the time. The maximum occupancy standard for an acute hospital is acknowledged to be 82% to 85%. This is predominantly driven by the requirement to have additional capacity available as required (in the form of escalation beds) and the risk of infection associated with higher levels of occupancy and therefore patient throughput. There are at present no published standards of occupancy specifically for community hospitals. The group were advised that the incidence of infection is considerably lower and the average length of stay for the community wards are generally higher than that of an acute ward setting. Each group wished to discuss how Dorking Hospital is achieving these current levels, and addressed concerns at whether high occupancy levels and lower length of stays would compromise patient satisfaction, clinical outcomes or risk of infection. On considering these factors if was noted that Dorking Hospital has not experienced an increase in the incidence of hospital acquired infections when compared with the other hospitals and that patient satisfaction also remains high. It is therefore possible to assume that the levels of occupancy at Dorking are not having an adverse impact on the patient care. If the sites were to operate at between 90% and 95% bed capacity would increase still further. The table below shows the impact on capacity of improved length of stay and increased levels of occupancy. Table 6 - Increased occupancy - decreased average length of stay Average Site Beds % Occupancy Annual bed Days length of stay Patient volumes Dorking 28 95% 9709 14 694 Molesey 12 95% 4161 14 297 NEECH 20 95% 6935 14 495 Leatherhead 0 14 0 Total 60 1486 By maintaining an average occupancy of 95% and an average length of stay of 14 days the increase in patients able to be seen in current bed capacity is 40%. This is sufficient capacity to have a 6% increase in demand year on year for the next 10 years. As per the population growth noted in tables 1 and 2, such capacity is unlikely to be required, particularly in before 2020.
Population geography The group looked at where the population is located across Surrey Downs as part of trying to understand where services should be best placed. Using risk stratification data it was possible to see how each individual practice population was made up. This data was then condensed into the original four localities of Surrey Downs CCG and the graph below created. Please note that Medlinc and Mid Surrey now cover all GPs within the Epsom locality, which includes Leatherhead, Ashtead, Bookham, Fetcham, Banstead, Epsom, Ewell and surrounding villages. Graph 4 - Population split by health risk 45% 40% 35% 30% 25% 20% 15% East Elmbridge MEDLinC Mid Surrey Dorking 10% 5% 0% Non-users Healthy Low Moderate High Very High The group were advised that community hospital inpatient services are accessed by those patients in High and Very High risk categories. The graph clearly shows the majority of the population are in the MEDLinC / Mid Surrey locality, now known and the Epsom locality. It is logical to therefore assume that a large percentage of the community hosppital inpatient provision should be located within reach of the Epsom locality. At present the population is serviced by both NEECH and Dorking, and previously at Leatherhead. The East Elmbridge locality accounts for only 15% of the patient population, however there will still be demand for community rehabilitation services. Neurological rehabilitation services Each workshop then went on to talk about the neurological rehabilitation services. Surrey Downs has both inpatient and outpatient rehabilitation services for patients
who have suffered neurological problems including stroke and acquired brain injury (ABI). The services are based at the NEECH site with the outpatient function in the Poplars unit and the 4-bed inpatient unit on the ward. There was some debate as to whether there is a need to increase the capacity of the inpatient service. Much research has been undertaken into the outcomes of patients who have suffered from stroke or ABIs (aquired brain injury). Clinical outcomes show that rehabilitation services have proven most effective when delivered from dedicated specialist units with staff trained in the care and management of patients with neurological deficits. The group discussed the NEECH ward, which has four beds specifically for patients requiring neurological rehabilitation. These beds are part of the 20-bed ward with the other 16 beds being used for general rehabilitation. The neurological beds have a separate team of therapists specifically trained in neurological rehab. NEECH has so far provided neurological rehabilitation for 28 patients in the last 12 months. Of these 18 patients have been under 65 years with the remaining 10 being over 65 years. The rehabilitation unit receives patients from a number of referring sources. The majority of patients are referred from Epsom Hospital (17) with other from Kingston Hospital, Royal Surrey, St Georges and St Peters. The four beds are almost always full with over 90% occupancy. The average length of stay for patients receiving neurological rehabilitaton is 59 days, compared to 22 days for the general rehabilitation services in NEECH. The majority of patients are discharged to their home from the rehabilitation service with only a small number of the 28 patients being placed in long term care. Group discussion summary The following items were raised as discussion points throughout these workshop sessions, and during the examination of data. Where items/ideas still require exploration, these will be developed by the CCG and brought to the next set of workshops in July. Our community hospital inpatient services are currently working well to meet population needs. If we do nothing, we have identified that bed capacity would need to increase in the next 5 years. However, we do not need to increase capacity if we use identified best practice to decrease length of stay and increase occupancy levels. These projections also take no account of other planned initiatives including the introduction of community medical teams. Factors affecting this include: Optimum ward sizes general view inpatient wards should have a minimum of 20 beds for clinical safety and staffing levels.
Optimal ward sizes to accommodate different sexes Where units are smaller wards have less capacity to accommodate one sex, if a bed is only available for the other. For example a male patient waiting for a ward space, when only a female bed is available. Larger wards have more flexibility to move capacity around and take on patients of either sex, whilst still maintaining single-sex standards. Discharge nurse co-ordinators Since the implementation of a dedicated discharge nurse co-ordinator at Dorking, the hospital is able to focus on discharging patients, without taking time away from nurses focusing on current patient care More integrated care Dorking hospital (through their Discharge nurse coordinator) have established strong links with establishing support packages for those leaving hospital. The establishment of Community Medical Teams (discussed during previous workshops) based around community hospital sites will also help to identify and support patients at greater risk of requiring acute care or readmission. CMTs will also provide a single point of access for patients who can be looked after at their place of residence, instead or requiring an admission to an acute or community hospital. It was identified that there are no clear national guidance or standards relating to best practice in community hospitals. However discussions have identified that: All current inpatient services (including Leach ward) meet CQC standards, show high levels of care and high levels of patient satisfaction Larger specialist units to provide specialist care (e.g. neuro, stroke) are required and benefit from economies of scale As above, optimal ward sizes and dedicated discharge nurse co-ordinators are identified areas showing best practice across Surrey Downs. There is possibility to roll out to other inpatient units. Patient transport was again raised as a key link service to all discussions. It was generally felt that this needs reviewing and improving, which is being taken forward by the CCG. Finally, all groups discussed potential alternative models for care. These included: Centralisation can we combine services to improve clinical outcomes is it okay to travel slightly further for better care? Community beds in acute hospitals Looking at the improvements in length of stay and occupancy when NEECH beds temporarily moved to Croft ward in Epsom Hospital during 2014. All groups agreed that this showed excellent patient care, but that both staff and patients prefer the community hospital environment. It was agreed though that a lot of good lessons were taken from this, which was later reflected when the beds moved back to NEECH.
Day therapy unit Patients who are safe at night could be brought in to community hospitals for day therapy, without the need for beds. This idea was generally thought of as good, but should be explored if patients are safe and have home support. It is important that the correct care package is in place for this to work. Also, is there evidence that this works? These points will be developed further and discussed as part of the development of future models of care, during workshop 4. Next meetings The next four workshops will be held in the third week of July and are as follows: Monday 13 July, 18:00-20:00 at Imber Court Sports Hall, Ember Lane, East Molesey, KT8 0BT Tuesday 14 July, 13:00-15:00 at Dorking United Reformed Church (Little chapel), 53 West Street, Dorking, RH4 1BS Wednesday 15 July, 18:00-20:00 at Leatherhead Hospital (Community Assessment Unit room), Leatherhead Thursday 16 July, 13:00-15:00 at Church House (Main hall), Church Street, Epsom, KT17 4PX They will focus on exploring "future models of care", considering where we are to date and how we can bring current services into line with on-going local population needs. Places are limited and it is essential to register before the events. To book your place, or for more information, please email contactus.surreydownsccg@nhs.net or call 01372 201793.
Notes from the public workshops Esher Monday 8 June King George s Hall Attendance: 11 Dorking Tuesday 9 June United Reformed Church Attendance: 3 Amongst the attendees at the workshop in Esher included members of the Molesey Hospital and Thames Ditton Hospital League of Friends groups, Cobham, local residents and resident association members, patients and carers, Save Our Surrey Community Hospitals. Attendees at this workshop were made up from local residents, current and previous patients. Additional notes: An agreement that more therapies are needed. TE to explore as part of the review. A belief that community hospitals may not have the same access to social care as acutes and that this should be checked/explored TE is still to visit Emberbrook clinic, although he has seen the nursing home side. For outpatients the need to see if all referral pathways are being followed and that unnecessary diagnostics (such as xrays) are not being performed. TE talked about the planned care reviews and how pathways are checked through this route, not this review. TE will raise with planned care lead. Asked to also consider outpatient services that were previously delivered and are not now. The need to work with the rest of Surrey, to ensure that plans are not made in isolation. Can beds at Molesey be used for convalescent care? Support for a day therapy unit and a desire for this idea to be developed further and fed back. Additional notes: To note additional services which support the hospital, such as the quality of food at Dorking. A great improvement noted with Dorking, especially from the introduction of a discharge nurse co-ordinator 6 months ago. Differences noted between the flexibility of small units versus large ones and how Dorking is better able to provide beds for male and female patients when a larger unit.
The quality of rehabilitation is also based on family and support. Therefore need to look at factors such as transport for visitors if far away, parking and the availability of nursing home beds in the community. There is currently GP support based at Dorking, which has allowed the unit to evolve and have GPs on hand. This would be advantageous to other hospitals and the development of CMTs would aid this. Patient transport preference of local organisations, such as Red Cross for general transport. Belief that a fully equipped ambulance is not needed for some patient journeys. Neuro services is demand increasing because of better treatment links and diagnosis which previously would have resulted in death? This is possible and could be researched further, although more important to simply note that there is an increase in demand. The need for community and acute hospitals to be able to handle multiple conditions. Idea that some patients do not wish to leave community hospital if they feel they are going into a nursing home permanently. The idea that patients can go to a nursing/care home for a small period of respite before going home, without feeling that they have to stay permanently. Leatherhead Wednesday 10 June Leatherhead Hospital The workshop in Leatherhead had the largest attendance and included local residents, League of Friends members, social care representatives, Surrey County Council representatives, Patient Participation Group members, Additional notes: Comment that respite care is being reduced and that this is having an impact on hospital admissions Comment that Cobham hospital has a good ward space and a nice environment and that should be used in future. However, it was noted that transport links are limited
Attendance: 29 Healthwatch and a local councillor. When the group were discussing the temporary relocation of the NEECH community ward to Epsom General Hospital, transport was noted as a concern if this arrangement were to be reinstated. Are you working with social care to address discharge issues? TE confirmed that the CCG is working with partners including social care. If quality of care is the same across all hospitals, why has the Leatherhead ward remained closed? TE explained that this was due to staffing and recruitment issues. It was noted that some local trusts had recruited from abroad. CSH Surrey added that as staff do not receive a full London weighting as part of their salary in Surrey, positions are seen to be less attractive, despite recruitment campaigns. Some members raised concerns about the use of agency staff. However it was noted that if staffing was an issue, this was the only alternative. It was also noted that in many cases the same agency staff return so there is some level of continuity if the use of agency staff is planned. What occupancy rate are we aiming for in community hospitals? TE explained that acute trusts aim for 85% occupancy so they have additional capacity available if required and that we should be aiming for a similar occupancy level There was a comment that larger wards seem to perform better. TE confirmed that larger wards can be more flexible in how they accommodate patients (for example by changing male and female beds to accommodate the patient coming in)
Discussing discharge planning and the importance of this in using community beds effectively, it was suggested that the smaller inpatient wards shared a discharge planner so they could benefit from this role. Comment that some Leatherhead patients stay at Molesy. SL explained that if a community bed becomes available patients are given a choice on whether they want to be transferred. Question: Shouldn t community hospitals be able to refuse admissions that are inappropriate? The group discussed issues with patient transport and heard an account of one patient waiting over five hours to be collected from a hospital. TE confirmed that the CCG are taking steps to address this. Discussing plans for new community medical teams, concerns were raised about transport being an issue for this new service and that this would need to be considered One member of the group asked for confirmation of plans for Leatherhead Hospital, particularly in relation to beds and whether they would be returning. TE explained that as the review is still taking place, it is too soon to know what, if any, changes may be proposed. Question: If one of the hospitals does close, who gets the money? TE confirmed that in the event of a site closure, NHS Property Services would get any money from sale of the property as they own the estate Discussing how people felt about the temporary relocation of the NEECH ward to Epsom Hospital, one member of the group
commented that as an Epsom patient they were very happy with the ward when it moved to Epsom Hospital. They felt the ward worked well as it gave medical professionals access to a wider range of services on the site. Another member of the group commented that if the community ward moved to Epsom, it would loose its identity as a community site, which they felt helps support rehabilitation. Question: Can Gascoigne ward (currently used as office space at Leatherhead Hospital) be turned back into a hospital ward? TE confirmed that the review was looking at the entire estate and how buildings are used, as well as services provided. Discussing types of patients that use community hospital, it was felt that end of life care and respite care patients would be more appropriately cared for in other settings. Epsom Thursday 11 June St Joseph s Catholic Church Attendance: 6 Attendees included local residents, NEECH Guild of Friends members, patients and a carer Additional notes, comments and questions: Comment that preference for NEECH over Leatherhead as the beds in Leach ward for females are too open as males walk past. Also very noisy from TV room. Discussion over number of beds which is seen as best should you have a 50 bed ward? TE discussed optimal size appears to be 20-30 Agreement that the NEECH move to croft saw an improvement in care when the beds moved back to NEECH. However, feelings that patient and staff satisfaction is greater at NEECH and that croft ward is needed winter pressures space for Epsom. Also that croft is dark and dingy, which can affect a patients mood. Also fears that if the community ward moved into an acute, eventually it would become an acute ward.
Does NEECH need an x-ray? No current clinical need, but could be required as population needs increase at a later stage. Previously NEECH used a telecare-type system where patients took ipads home and could skype ward staff with issues and hold medication up to camera etc. This would be looked into further by TE. However, development of community medical teams would increase access for patients at risk. Also, technical equipment is not easy to use if not done regularly.